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Alternative Treatments for Chronic Pain
MICIS Workshop Speakers:Peter Michaud, RN, JD
Elisabeth Fowlie Mock, MD, MPHGordon Smith, JD
Disclosures
MICIS does not accept any money from pharmaceutical companies
This presentation includes “off label use” of medications
Materials May Include: “un-ad” one page handout for each topic
Update on ME laws slide set
How to Use Naloxone (pt brochure)
Chapter 21 rules
DHHS prescription guide
National/state numbers
Resource documents at MICISMAINE.org
Learning Objectives
Discuss alternative treatments for chronic pain management
Highlight a team based approach to care for patients living with chronic pain
Understand ways to reduce pain by addressing the physical, psychological, social and spiritual components of pain
Outline
Introduction
Nonpharmacological treatments
Pharmacological treatments (non-opioid)
Best practices
Chronic Pain Best Practices
Multiple approaches
Utilized in concert
Coordinated
Multidisciplinary team
Medication not sole focus of treatment
Set reasonable expectations
Nociceptive Pain
Neuropathic Pain
HARM REDUCTION/HEALTH PROMOTION
Access to NALOXONE
Avoid co-prescribing benzos and opioids
Identifying OUD and referring to treatment
BEST PRACTICE EXAMPLES
Mercy Pain Center-integrated chronic pain treatment
– 1/14/16 Quality Counts webinar “Expanding the Team”
– https://www.youtube.com/watch?v=-C6D8Q5OZlU&feature=youtu.be
– http://mainequalitycounts.org/wp-content/uploads/2018/01/Presentation-Slides-8.pdf
Harrington Health Center-mapping of complementary medical neighborhood
NONPHARMACOLOGICALBrainstorming exercise & discussion
NONPHARMACOLOGICAL APPROACHES Behavioral
Exercise/touch
Anti-inflammatory diet
Complementary practitioners
Energies
Interventional approaches
Emerging therapies
BEHAVIORAL
Cognitive behavioral therapy (CBT)
Individual & group counselling
Biofeedback
Mindfulness
Relaxation therapy
Psychotherapy
Hypnosis
Meditation
Guided imagery
Balneotherapy
EXERCISE/TOUCH
Aerobic
Aquatic
Yoga
Tai Chi; QiGong
Massage
Reflexology
Therapeutic touch
Kinesiology tape
ANTI-INFLAMMATORY DIET
Plant-based foundation
Fiber rich
Limited saturated fat, no trans fat
Omega-3 fatty acid rich
Avoid processed foods & refined sugars
Nuts and seeds
Avoidance of gluten and/or dairy
COMPLEMENTARY PRACTICES
Osteopathic manipulation
Acupuncture
Physical therapy
Occupational therapy
Chiropractic
Music therapy
ENERGIES Ultrasonic stimulation
Electrical neuromodulation
– Transcutaneous electrical nerve stimulation (TENS)
– Spinal cord stimulation
Thermal application (heat/cold)
Reiki
Whole body vibration
Infrared therapy
INTERVENTIONAL APPROACHES
Ablative techniques
Botulinum toxin injections
Nerve blocks
Trigger point injections
Epidural steroid injections
Minimally invasive surgical techniques
EMERGING THERAPIES
Virtual reality i.e. “SnowWorld”
– Acute/peri-operative pain
– Chronic pain
Understanding Pain: Brainman Chooses
https://www.youtube.com/watch?v=jIwn9rC3rOI
Best Practices
Calais orthopedic surgery group-taper off opioids preop for elective cases
Bucksport Regional Health Center-”Pain on the Brain” required curriculum through behavioral health & palliative care exemption committee case review
PHARMACOLOGICAL
Brainstorming exercise & discussion
PHARMACOLOGICAL APPROACHES
Nonopioid Analgesics
Antidepressants
Anticonvulsants
Adjuvants
Natural medicines
– Anti-inflammatory
– Antidepressants
– Misc.
Nonopioid Analgesics
Acetaminophen
NSAIDs-naproxen
– Platelet aggregation inhibition
– GI: dyspepsia & gastric ulceration
– Nephrotoxicity
– Cardiovascular
COX-2 inhibitors-celecoxib
Antidepressants
Tricyclics (TCAs)
– Desipramine & nortriptyline
– Amitriptyline
Serotonin norepinephrine reuptake inhibitors (SNRIs)
– Venlafaxine
– Duloxetine
Selective serotonin reuptake inhibitors (SSRIs)
Anticonvulsants
Gabapentin
Pregabalin
– Topiramate
– Lamotrigine
– Levetiracetam
– Phenytoin
– Valproate
– Carbamazepine/oxcarbazepine
NOT Benzodiazepines (esp clonazepam)
Adjuvants
Topicals—lidocaine, capsaicin, NSAID, doxepin
Antispasmodics/muscle relaxants (not carisoprodol)
Botulinum toxin
Cannabis & cannabinoids
Natural medicines-Anti-inflammatory
Bromelain
Cat’s Claw
Devil’s Claw
Stinging nettle
Turmeric
Willow bark
Natural medicines-Antidepressants
5-HTP
L-tryptophan
St. John’s wort
Acetyl-L-carnitine
Alpha-lipoic acid
Counterirritants:
– Camphor
– Capsicum
Natural medicines-Misc
Arnica
Avocado
Cetylated fatty acids
Chrondroitin sulfate
Comfrey
Glucosamine sulfate (+HCl)
Marijuana/cannabis
MSM
N-acetyl glucosamine
SAMe
Soybean oil
Many others
Cannabis--Benefits
High-quality evidence for several conditions
Possible decrease in opioid use for chronic pain (causality not shown)
No respiratory depression, not lethal in overdose
For some patients, financially accessible by growing own supply
Cannabis—Side Effects
Risk of use disorder 9% in general public, higher in patients prone to “chemical coping”
Chronic bronchitis (smoking/inhaled)
Psychosis and anxiety
Cognitive dysfunction—drop in IQ temporary in adults, can be permanent in adolescents
Doubled risk of motor vehicle crashes while under the influence
Cannabis--Unknowns
Barriers to scientific study due to Schedule 1 status
Thousands of chemicals in the plants—difference species and variable concentrations of THC and CBD
Incentives for big tobacco, venture capitalists and state governments—as of early 2018, a $7 billion industry
PCSS podcast—fantastic overview of non-opioid treatments and studies
Naltrexone at microdoses
Episode 8: Non-opioid pharmacological management of chronic pain, 5/23/17
– http://pcsspodcast.org/non-opioid-pharmacological-management-of-pain
Reference #1-UpToDate Article(requires subscription)
“Overview of the treatment of chronic non-cancer pain”
– Last update 11/30/17, literature review through Jan, 2018
Graphic 2-page 13 ‘Neuropathic pain: Pharmacologic approach’
Graphic 3-page 14 ‘Nociceptive pain: Pharmacologic approach’
Graphic 4 comparison on NSAIDs
Graphic 6 comparison of SEs of antidepressants
Reference #2-Prescriber’s Letter (subscription required)
Multiple summaries, guidelines & charts for chronic pain tx
Natural Medicines in the Clinical Management of Pain, Vol 15, No 106, Self-study course #150106
MICISmaine.orgChronic Pain Toolkit
Highlighted Resources in Toolkit
CDC 2 page handout on chronic pain tx
– https://www.cdc.gov/drugoverdose/pdf/nonopioid_treatments-a.pdf
NIH Chronic Pain in Depth
– https://nccih.nih.gov/health/pain/chronic.htm
NIH e-book Pain: Considering Complementary Approaches
– https://nccih.nih.gov/health/pain/ebook
In Summary...
➢ A multitude of nonpharmacological options can benefit patients in acute and chronic pain
➢ Management of both acute and chronic pain is most effective when done by teams
➢ Pain is complex and has multiple dimensions: physical, psychological, social and spiritual
other references: MICISMaine.org